Bloodborne Pathogen Exposure Control Plan - University of ...

BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN
UNO Campus Safety Policy
POLICY
It is the policy of the University of Nebraska at Omaha (UNO) to protect employees who, in the
course of their work, may contact bloodborne pathogens (human body fluids and tissues). For
additional information regarding pathogens, refer to Biosafety Guidelines UNMC/UNO
(research issues) and the Institutional Policy on Infectious Diseases (copies on file in
Environmental Health and Safety Office).
EXPOSURE DETERMINATION
1. Exposure determinations identify who will receive training and be offered Hepatitis B (HBV)
vaccination. These determinations also identify what measures must be taken to minimize
exposure incidents. Exposure determination has been separated into three classifications:
CLASS I is a listing of those job titles in which all employees have potential for occupational
exposure to human blood, body fluids, or other infectious materials. Employees (including
student employees) in Class I will receive annual training and be offered HBV vaccination.
CLASS II is a listing of those job titles whose tasks may result in occupational exposure.
Employees (including student employees) in Class II will also receive annual training and be
offered HBV vaccination. CLASS III are employees in areas where injuries are likely to occur.
Individuals in Class III will receive training every three years.
Examples of tasks that place an individual at risk are listed in Appendix A. Class determinations
are made by identifying the tasks that may lead to bloodborne pathogen exposure and by
confirming that the tasks are part of an individual's normal job responsibility. Assisting or
rendering first aid to an employee or student is not considered an employment related risk factor
unless it is part of your normal job responsibility.
2. Using the form provided (Form I), department chairpersons must identify by job description
reasonably anticipated exposure to human body fluids and tissues. Determination must be made
without regard to personal protective equipment or frequency of exposure. Departments must
send the list to the Environmental Health and Safety Office for review by the Bloodborne
Pathogen Exposure Control Committee. Lists must be reviewed annually, and when any new or
modified tasks might affect employee exposure. Reviewed lists must be resubmitted by October
1 each year.
A. Department Chairpersons are responsible for seeing that the methods used to protect
employees are based on universal precautions. Methods will be reviewed by the Bloodborne
Pathogen Exposure Control Comm.
B. Training will be scheduled by the employee's department. (See Training and Recordkeeping.)
EXPOSURE CONTROL - WORK PRACTICES

1. Engineering and workplace controls (see 2-8 below) must be used to eliminate or minimize
exposure. Personal protective equipment, i.e., gloves, masks, faceshields, must be used whenever
there is an exposure potential.
2. Hand-washing facilities must be available when feasible.
A. Employees must wash their hands immediately upon direct skin contact and always after
removal of gloves or other protective equipment.
B. Flush eyes and/or mucous membrane areas immediately with water if those areas have come
into contact with blood.
3. Sharps (needles, scalpels, razor blades, contaminated glass) procedures:
A. Do not bend, recap, or remove from syringes unless it can be demonstrated to the Bloodborne
Pathogen Exposure Control Committee that no other feasible method exists or that such action is
required by a specific medical procedure.
B. Shearing or breaking of contaminated needles is prohibited.
C. Never reach into or force items into a sharps container. Containers must be accessible and
located as close as possible to the area where sharps are used or found. They must be kept
upright throughout use, replaced routinely, and not be allowed to overfill.
D. Contaminated reusable sharps must be placed in containers that are puncture-resistant,
labeled, and leakproof on sides and bottom until properly reprocessed. Storage and processing
procedures must not be used which require employees to reach by hand into these containers.
4. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are
prohibited in areas where there is a reasonable possibility of exposure.
A. Food and drink must not be kept in refrigerators, freezers, shelves, cabinets, or countertops or
benchtops where blood or other potentially infectious materials are present.
B. Mouth pipetting/suctioning of blood or other potentially infectious material is prohibited.
5. All procedures involving blood or other potentially infectious materials must be performed in
a manner that minimizes splashing, spraying, spattering, and generation of droplets.
6. Specimens of blood or other potentially infectious material must be placed in a container that
prevents leakage during collection, handling, processing, storage, transport, or shipping.
Specimen containers must be labeled and closed prior to being stored or transported when
universal precautions are not utilized. Specimen containers shipped off campus must be labeled.
A. The primary container must be placed in a labeled or secondary container that prevents
leakage when outside contamination of the primary container occurs.

B. The primary container must be placed in a labeled, puncture-resistant secondary container if
the specimen could puncture the primary container.
7. The worksite must be kept in a clean and sanitary condition. All equipment and work surfaces
must be cleaned and disinfected after contact with blood or other potentially infectious material.
Equipment that may become contaminated with blood or other potentially infectious materials
must be examined prior to servicing or shipping and must be decontaminated if possible. The
person using the equipment is responsible for decontamination.
A. A label must be attached to the equipment stating which portions remain contaminated.
B. Information must be conveyed to all affected employees, servicing representatives, and/or
manufacturers prior to handling, servicing, or shipping so that appropriate precautions can be
taken.
8. RESEARCH LABORATORIES dealing with human pathogens must determine the level of
risk. They must meet the requirements as directed by the Biosafety Guidelines of UNMC/UNO.
Reference that document for information on procedures in research laboratory environments.
EXPOSURE CONTROL - PERSONAL PROTECTIVE EQUIPMENT
Employees must use appropriate personal protective equipment, provided at no cost to the
employee. It must be readily accessible and in a variety of sizes. Appropriate protective
equipment includes but is not limited to: gloves, masks with face shield, CPR mouthpieces.
Protective equipment must be worn under the following conditions:
A. Gloves - must be worn when it is reasonably anticipated that the employee may have hand
contact with blood or other body fluids and when handling or touching contaminated items or
surfaces.
1. Disposable gloves must be replaced as soon as practical when contaminated, or as soon as
feasible if they are torn, punctured, or when their ability to provide an effective barrier is lost.
Disposable gloves must not be washed or decontaminated for reuse.
2. Utility gloves may be decontaminated and reused if the integrity of the gloves is not
compromised.
They must be discarded if cracked, peeling, torn, punctured, or exhibiting other signs of
deterioration.
B. Masks and eye protection, (glasses, goggles or face shields) must be worn whenever there is
the possibility that splashes, spray, or droplets of blood or other potentially infectious materials
may be generated, which could contaminate eye, nose, or mouth.
WASTE DISPOSAL AND LAUNDRY

1. Special precautions must be taken when disposing of infectious waste. All infectious waste
must be put in red (biohazard) bags and placed in containers located at Health Services, Athletic
Training, Campus Recreation (Central Issue), and Milo Bail Student Center. Biohazard waste is
transported and disposed by a contractor.
A. Mechanical means, such as a brush and dust pan, must be used to pick up potentially
contaminated broken glassware.
B. Broken contaminated glassware and sharps must be placed in sharps containers prior to
disposal.
NOTE: Glass disposal is a potential hazard for departmental and environmental personnel. Glass
should be placed in a puncture-resistant container and labeled that it contains GLASS.
2. Contaminated laundry must be handled as little as possible.
A. Wet contaminated laundry must be placed and transported in bags or containers that prevent
soak-through or leakage to the exterior.
B. Employees who have contact with contaminated laundry must wear gloves and other
appropriate personal protective equipment.
HEPATITIS B VACCINE
1. Hepatitis B vaccines must be available to Class I and II employees (including student
employees), within 10 working days of assignment.
A. The University will cover the cost of the vaccinations for University employees.
B. Employees who choose not to be vaccinated must sign a declination form (Form II); they may
later opt to receive the vaccine at no cost.
2. Students with the potential for exposure to blood and other body fluids as part of their
academic program must show proof of initial vaccination with Hepatitis B to enter the program.
The student must complete the vaccination series within six (6) months. The student is
responsible for the vaccination costs.
POST EXPOSURE PROCEDURES
Following an exposure incident at UNO, employees and students must immediately report to
Health Services during business hours. Students and employees must report to an emergency
room (preferably UNMC) after hours. Employees must also notify their supervisor of the
exposure incident.
A. Employees, including student employees, who report to Health Services or the emergency
department will receive a confidential medical evaluation and follow up which must include

testing the worker's blood upon consent (at no cost to the worker), post-exposure preventive
treatment, and counseling.
B. A copy of the evaluating health care professional's written opinion must be provided to the
employee within 15 days of the evaluation.
LABELING
1. Warning labels must be affixed to containers of infectious waste: refrigerators and freezers
containing blood or other potentially infectious material, and other containers used to store,
transport, or ship blood or other potentially infectious material except for the following
exemptions.
A. Red bags or red containers may be substituted for labels.
B. Individual containers of blood or other potentially infectious materials that are placed in a
labeled container during storage, transport, shipment or disposal.
2. Labels must include the BIOHAZARD legend and symbol. Labels must be fluorescent orange
or orange-red, or predominantly so, with lettering or symbols in contrasting color.
A. Labels should be affixed as close as possible to the container by string, wire, adhesive, or
another method that prevents loss or unintentional removal.
B. Labels for contaminated equipment must meet the specifications above, and must state the
portions of the equipment which remain contaminated.
TRAINING AND RECORDKEEPING
1. Trainers must be "certified" to conduct these classes. Training materials and instructor
certification is available from Environmental Health and Safety. Contact Environmental Health
and Safety for information and instructor availability.
2. All employees will review and receive the Bloodborne Pathogen Exposure Control Plan
summary statement during employee orientation.
3. For employees with occupational exposure (Classes I and II), annual training must be provided
during working hours at no cost to the employee. Training must meet a specific set of criteria,
and is available from Environmental Healt and Safety.
4. Employees who work in areas where injuries occur more frequently due to the nature of their
vocation or lab content (Class III) should receive initial training and refresher training every
three years thereafter.
5. Training records, which include the following, must be kept: dates of training sessions;
contents and summary of training sessions; names and qualifications of persons conducting the

training; and names and job titles of all persons attending the training sessions. Training
documentation forms are available from Environmental Health and Safety.
6. Training records must be maintained for three years from the date on which the training
occurs. Training records will be kept in Environmental Health and Safety and in the individual's
department file.
7. A medical record must be maintained in Health Services for each employee with occupational
exposure. Among the
items the record must contain are a copy of the employee's Hepatitis B status, dates of all
Hepatitis B vaccinations and any medical records relative to the employee's ability to receive
vaccination, a copy of all results of any post-exposure evaluations and follow-up procedures, and
a copy of the information provided by the health care professional, if applicable.
A. Medical records will be kept confidential and not disclosed or reported without the
employee's written consent, except as required by law.
B. The records must be maintained for at least the duration of employment plus 30 years.
ENFORCEMENT
Employees not complying with the provision of this Plan will be subject to the disciplinary
measures outlined in the UNO employee handbook.
10/26/95
APPENDIX A
Exposure Determination
Tasks that may involve exposure to bloodborne pathogens include, but are not limited to the
following:
CLASS EXAMPLES
Administering vaccines or injections to humans
Administering first aid or CPR
Touching broken skin or mucous membranes
Handling, obtaining or performing tests with human body specimens
Cleaning surfaces or equipment that may be contaminated with
bloodborne pathogens
Handling laundry that may be contaminated with bloodborne pathogens
Disposing of biohazard waste "red bags" or "sharps" containers.
Class I
Job Title

Class II
Class III
Nurse
Security Officer
Athletic Trainer
Custodian
Job Title
Graduate Asst.,
Campus Rec
Student Worker,
Campus Rec
Job Title
Faculty - Chemistry,
Biology
Graduate Asst.-Chem.,
Biol.
Food Service
Plant Maint. and
Utilities
Grounds
Tasks and Assignments
Building Mgr, responds
to injury scene and
assists as necessary
Field Supervisor, " "
Central Issue - handles
soiled laundry, etc.
Tasks and Assignments
Assist injured students
in lab
Assist injured students
in lab
Assist injured coworkers
Assist injured coworkers
Assist injured coworkers
TRAINING AND VACCINATION SUMMARY
TRAINING
CONTENT
FREQUENCY
HEPATITIS B
VACCINATION
NEW
EMPLOYEES
Control Plan Summary
During new
employee orientation
No
CURRENT
EMPLOYEES
Control Plan Summary
Once through
Department staff
No
CLASS I & II
(Employees and
Students)
1. Control Plan
2. Video*
Annually
Yes

CLASS III
Employees in high
injury areas
1. Control Plan
2. Video*
(optional)
Every 3 years
No
* Video - Bloodborne Pathogens, by Summit Training 1992